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FreeportFireAdmin!!@
2015-10-02T19:19:52+00:00
Ambulance Application
Ambulance Application
Position applied for:
Available:
*
Full time
Part time
Hours
*
AM
PM
Nights
Saturdays
Sundays
Weekends
First Name
*
Last Name
*
Social Security Number
*
Phone
*
Address
*
Number/street
*
City/State
*
How referred to us
*
Personal Data
Do you have the legal right to live and work in the United States
*
Yes
No
Are you 18 and under 70 years of age?
*
Yes
No
Do you have any physical condition, which may limit your ability to perform the particular job for which you are applying?
Do you know of any reason you would need a leave of absence during the next 12 months?
Is there any reason you may terminate in the next 12 months?
In Case of emergency
In case of emergency notify:
Relationship
Address
Phone
Education
Grade School
1
2
3
4
5
6
7
8
High School
1
2
3
4
College/Vocational
1
2
3
4
Graduate
1
2
3
4
Name of last school attended
Address
Year Completed
Miscellaneous
Have you ever supervised the work of others?
How many?
Have you ever been dismissed from a job? Explain please.
Registry and/or License Number (Professional)
State in which held
Employment record/personal references
Position held: If you have no previous employment record, please list three personal reference and the length of time each has know you.
May we contact?
Yes
No
Employment/Reference 1
Company/Institution
Job Title & Brief Description
Supervisor
Reason for leaving
Phone
Employment/Reference 2
Company/Institution
Job Title & Brief Description
Supervisor
Reason for leaving
Phone
Employment/Reference 3
Company/Institution
Job Title & Brief Description
Supervisor
Reason for leaving
Phone
Employment/Reference 4
Company/Institution
Job Title & Brief Description
Supervisor
Reason for leaving
Phone
Drivers' License and Proof of Car Insurance
Driver License Number
Car Insurance Company
Current?
Upload copies of both drivers license and insurance proof.
Uploading Files. Please Wait.
Signature
Draw It
Type It
Clear
READ CAREFULLY AND SIGN
I clerisy that the completed information is correct and any misstatement could be cause for my dismissal. I authorize the investigation of all statements contained in this application and release any and all persons, companies or agencies from any liability or damages due to releasing information. Employment will be contingent on standards and satisfactory reference checks. If employed, I understand that I will be placed on probation for 90 days and upon termination I authorize the release of reference information.
